1. Name Of The Medicinal Product
Lemsip Max All In One Liquid
2. Qualitative And Quantitative Composition
Each 20ml dose contains:
Paracetamol 1000mg
Phenylephrine Hydrochloride 12.18mg
Guaifenesin 200mg
Cetylpyridinium Chloride 3.0mg
Each 20ml dose also contains potassium 23mg, sodium 19mg, propylene glycol 4300mg, sorbitol 3000mg, maltitol liquid 2000mg and ethanol 3000mg.
For a full list of excipients, see 6.1.
3. Pharmaceutical Form
Oral Solution
4. Clinical Particulars
4.1 Therapeutic Indications
For the short term symptomatic relief of the symptoms of colds and influenza, including aches and pains, headache, nasal congestion, tickly sore throat and chesty coughs.
4.2 Posology And Method Of Administration
For oral administration.
It is important to shake the bottle for at least 10 seconds before use.
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4.3 Contraindications
Patients with known hypersensitivity to paracetamol, phenylephrine hydrochloride, guaifenesin or cetylpyridinium chloride or any of the other ingredients.
Contra-indicated during pregnancy.
4.4 Special Warnings And Precautions For Use
The label should contain the following statements:
• Contains paracetamol.
• Do not give this medicine with any other paracetamol-containing product.
• For oral use only.
• Never give more medicine than shown in the table.
• Do not overfill the measuring cup
• Always use the measuring cup supplied with the pack.
• Do not give more than 4 doses in any 24 hour period.
• Leave at least 4 hours between doses.
• Do not give this medicine to your child for more than 3 days without speaking to your doctor or pharmacist.
• As with all medicines, if your child is currently taking any medicine consult your doctor or pharmacist before taking this product.
• Do not store above 25°C. Store in the original package.
• Keep out of the reach and sight of children.
• Immediate medical advice should be sought in the event of an overdose, even if you feel well, because of the risk of delayed, serious liver damage (leaflet).
• This product is not suitable for long term use.
• Paracetamol should be used with care in patients with severe renal or hepatic impairment. The hazard of overdose is greater in those with non-cirrhotic alcoholic liver disease.
• Do not take with other cold or decongestant medicines or any other paracetamol-containing products.
• Phenylephrine should be used with care in patients with hyperthyroidism, cardiovascular disease, diabetes mellitus, closed angle glaucoma, prostatic enlargement and hypertension.
• Do not exceed the stated dose.
• If symptoms persist consult your doctor.
Each 20ml dose contains 2g Liquid Maltitol and approximately 3g of Sorbitol. Patients with rare hereditary problems of fructose intolerance should not take this medicine. This product may have a mild laxative effect.
This product contains 19% (v/v) ethanol. Each 20ml dose contains up to 3g of ethanol (alcohol) equivalent to 32ml of wine or 76ml of beer. Harmful for those suffering from alcoholism. To be taken into account in pregnant or breast feeding women, children and high-risk groups such as patients with liver disease, epilepsy. The amount of alcohol in this medicinal product may alter the effects of other medicines. The amount of alcohol in this medicinal product may impair the ability to drive or use machines.
This product contains propylene glycol, which may cause alcohol-like symptoms.
4.5 Interaction With Other Medicinal Products And Other Forms Of Interaction
The speed of absorption of paracetamol may be increased by metoclopramide or domperidone; and absorption reduced by colestyramine. The anti-coagulant effect of warfarin and other coumarins may be enhanced by prolonged regular use of paracetamol with increased risk of bleeding; occasional doses have no significant effect. Alcohol may potentiate the hepatotoxicity of paracetamol.
Phenylephrine may reduce the efficacy of beta-blocking drugs and antihypertensive drugs; the product is contra-indicated in such circumstances.
With phenylephrine there is a possibility that an increased risk of arrhythmias may occur in patients receiving cardiac glycosides or tri-cyclic anti-depressants. Phenylephrine interacts with monoamine oxidase inhibitors; it should not therefore, be taken by patients receiving monoamine oxidase inhibitors or within 14 days of stopping such medication.
Guaifenesin may interfere with diagnostic measurements of urinary 5-hydroxyindoleacetic acid or vanillylmandelic acid.
4.6 Pregnancy And Lactation
Epidemiological studies in human pregnancy have shown no ill effects due to paracetamol used in the recommended dosage, but patients should follow the advice of their doctor regarding its use. Paracetamol is excreted in breast milk but not in a clinically significant amount. Available published data do not contraindicate breast feeding.
Phenylephrine should not be taken during pregnancy as it has been reported to cause foetal hypoxia. Excretion in breast milk is reported to be minimal.
Guaifenesin is considered safe for use in lactating women and at normal doses in pregnant women.
4.7 Effects On Ability To Drive And Use Machines
No studies on the effects on the ability to drive and use machines have been performed.
4.8 Undesirable Effects
Undesirable effects with paracetamol are rare, however, hypersensitivity including skin rashes may occur. There have been a few reports of blood dyscrasias including thrombocytopenia and agranulocytosis after regular or excessive ingestion of paracetamol, and of acute pancreatitis after ingestion of above normal dosage.
Undesirable effects are rare with normal doses of phenylephrine, however it can cause the adverse effects typical of sympathomimetics including: hypertension, palpitations (tachycardia), headache, dizziness, vomiting, diarrhoea and insomnia.
Guaifenesin has occasionally been reported to cause gastrointestinal discomfort.
4.9 Overdose
Liver damage is possible in adults who have taken 10g or more of paracetamol. Ingestion of 5g or more of paracetamol may lead to liver damage if the patient has risk factors (see below).
Risk factors
If the patient
(a). Is on long term treatment with carbamazepine, phenobarbitone, phenytoin, primidone, rifampicin, St John's Wort or other drugs that induce liver enzymes; or
(b). Regularly consumes ethanol in excess of recommended amounts; or
(c). Is likely to be glutathione deplete e.g. eating disorders, cystic fibrosis, HIV infection, starvation, cachexia.
Symptoms
Symptoms of paracetamol overdosage in the first 24 hours are pallor, nausea, vomiting, anorexia and abdominal pain. Liver damage may become apparent 12 to 48 hours after ingestion. Abnormalities of glucose metabolism and metabolic acidosis may occur. In severe poisoning, hepatic failure may progress to encephalopathy, haemorrhage, hypoglycaemia, cerebral oedema, and death. Acute renal failure with acute tubular necrosis, strongly suggested by loin pain, haematuria and proteinuria, may develop even in the absence of severe liver damage. Cardiac arrhythmias and pancreatitis have been reported.
Management
Immediate treatment is essential in the management of paracetamol overdose. Despite a lack of significant early symptoms, patients should be referred to hospital urgently for immediate medical attention. Symptoms may be limited to nausea or vomiting and may not reflect the severity of overdose or the risk of organ damage. Management should be in accordance with established treatment guidelines, see BNF overdose section.
Treatment with activated charcoal should be considered if the overdose has been taken within 1 hour. Plasma paracetamol concentration should be measured at 4 hours or later after ingestion (earlier concentrations are unreliable). Treatment with N-acetylcysteine may be used up to 24 hours after ingestion of paracetamol, however, the maximum protective effect is obtained up to 8 hours post-ingestion. The effectiveness of the antidote declines sharply after this time. If required the patient should be given intravenous N-acetylcysteine, in line with the established dosage schedule. If vomiting is not a problem, oral methionine may be a suitable alternative for remote areas, outside hospital. Management of patients who present with serious hepatic dysfunction beyond 24h from ingestion should be discussed with the NPIS or a liver unit.
The principal features of phenylephrine overdosage are a rise in blood pressure and associated reflex bradycardia. A severe hypertensive response can be countered by administration of an alpha-antagonist and any reflex bradycardia by atropine (but preferably only after the pressure has been controlled by alpha-adrenergic blockade).
Very large doses of guaifenesin may cause nausea and vomiting.
5. Pharmacological Properties
5.1 Pharmacodynamic Properties
Paracetamol has analgesic and antipyretic actions probably due to the inhibition of prostaglandin biosynthesis. It is effective against pain of mild to moderate severity, but is less successful against chronic pain.
Phenylephrine hydrochloride is a sympathomimetic agent with mainly direct effect on adrenergic receptors. It has predominantly alpha-adrenergic activity and is without significant stimulating effects on the central nervous system at usual doses. It may be given orally to relieve nasal congestion.
Guaifenesin is an expectorant which reduces the viscosity of tenacious sputum.
Cetylpyridinium Chloride is a cationic disinfectant with properties and uses similar to other cationic surfactants. These surfactants have bactericidal activity against Gram-positive and, at higher concentration against some Gram-negative organisms. Cetylpyridinium Chloride may be used in a variety of preparations for the local treatment of minor infections.
5.2 Pharmacokinetic Properties
Paracetamol is readily absorbed from the gastrointestinal tract and peak plasma concentrations usually occur 30 minutes to 2 hours after ingestion. Paracetamol is metabolised in the liver and largely excreted in the urine as sulphate and glucuronide conjugates. Less than 5% is excreted unchanged. The elimination half-life varies from about 1 to 4 hours.
Phenylephrine hydrochloride is irregularly absorbed after oral administration and undergoes first-pass metabolism by monoamine oxidase in the gut and liver, resulting in reduced bioavailability. Peak plasma concentrations are achieved in 1 to 2 hours. It is excreted in the urine mainly as the sulphate conjugate, with less than 20% as unchanged drug.
Guaifenesin is rapidly absorbed from the gastrointestinal tract. It is rapidly metabolised by oxidation to β-(2 methoxy-phenoxy) lactic acid, which is excreted in the urine.
Cetylpyridinium Chloride has only a local effect.
5.3 Preclinical Safety Data
There are no preclinical safety data on these active ingredients in the literature of relevance to the prescriber or to the recommended dosage and use of the product which are additional to that already included in other sections of the SPC.
6. Pharmaceutical Particulars
6.1 List Of Excipients
Liquid Maltitol (E965)
Sorbitol (E420)
Ethanol
Propylene Glycol (E1520)
Glycerol (E422)
Saccharin Sodium (E954)
Sodium Cyclamate (E952)
Acesulfame Potassium (E950)
Sodium Citrate (E331)
Anhydrous Citric Acid (E330)
Xanthan Gum (E415)
Levomenthol
Eucalyptus Oil
Quinoline Yellow (E104)
Patent Blue V (E131)
Purified Water
6.2 Incompatibilities
Not Applicable.
6.3 Shelf Life
2 Years.
6.4 Special Precautions For Storage
Do not store above 25°C.
Keep the container in the outer carton.
Keep the container tightly closed.
6.5 Nature And Contents Of Container
Clear type III glass bottle and polypropylene child resistant closure with aluminium foil film liner containing 160ml.
Clear PET bottle and polypropylene child resistant closure with aluminium foil film liner containing 160ml.
Graduated polypropylene measuring cup
6.6 Special Precautions For Disposal And Other Handling
No special requirements.
Any unused product or waste material should be disposed of in accordance with local requirements.
7. Marketing Authorisation Holder
Reckitt Benckiser Healthcare (UK) Limited
Dansom Lane
Hull
HU8 7DS
8. Marketing Authorisation Number(S)
PL 00063/0625
9. Date Of First Authorisation/Renewal Of The Authorisation
04/01/2010
10. Date Of Revision Of The Text
08/11/2011
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